RISK FACTORS :
β’ Age over 40
β’ Low residue diet
β’ Previous diverticulitis
β’ Number of diverticula in the colon
APPROPRIATE HEALTH CARE :
β’ Diverticulosis - outpatient with fi ber supplements to soften stools
β’ Outpatient diverticulitis (pain, tenderness, leukocytosis, but no toxicity or peritoneal signs)
β’ About 2% subjects require hospitalization for toxicity, septicemia, peritonitis or failure to resolve in a few days. About half of these will require surgery.
β’ Toxic patients require hospitalization and intravenous antibiotics at least until response
GENERAL MEASURES:
β’ IV fluids, analgesics, nasogastric suction
β’ Indications for surgery - severe diverticulitis, perforation, abscess, fistula, severe diverticular bleeding
(requiring more than 2,000 mL of blood in 24 hours), recurrent episodes
SURGICAL MEASURES :
β’ Usual indication related to diverticulitis. Multiple attacks in 2 years, unhealing fi stulae, abscess or toxicity may lead to surgery.
β’ Large pus collections are usually drained radiologically and when resolved, the most involved segment of the
colon resected
DIET :
β’ NPO during acute diverticulitis, progress to fluids, then to high fi ber as normal bowel function returns
β’ All patients with diverticula should increase dietary fiber to high level through foods, and/or fiber supplement if appropriate
PATIENT EDUCATION :
β’ Importance of high fiber diet and recognizing the symptoms of complications at early stage
DRUG(S) OF CHOICE :
. Diverticulosis
. Pain syndromes may be treated with antispasmodics
- hyoscyamine (Levsin) 0.125 mg or 2 each 4 hours; buspirone (BuSpar) 15-30 mg/day; or meperidine
(Demerol) 100-150 mg/day along with high fiber diet
. Constipation and diarrhea, manage as indicated for irritable bowel disease
. Diverticulitis
. Oral treatment for mild disease - metronidazole (Flagyl) 250-500 mg q 8 hours and amoxicillin 500 mg q 8 hours combination, or ciprofloxacin 500 mg bid. Expect response within 3 days. Continue oral therapy
for one week.
. More severe cases in hospital - gentamicin 3-5 mg/kg/day plus clindamycin 1.8-2.7 gm/day along with analgesic. Aminoglycoside dose varies with creatinine clearance.
. Diverticular bleeding
. Vasopressin 0.2-0.3 units/minute through selective intra-arterial catheter. Used when bleeding demonstrated
at angiography.
PATIENT MONITORING :
β’ Some physicians would not do any invasive studies; others have recommended repeat barium enema every
3 years if symptoms infrequent or absent, or following corrective surgery
β’ Colonoscopy, if needed based on above results
PREVENTION/AVOIDANCE : High fiber diet, psyllium, agar, methylcellulose
POSSIBLE COMPLICATIONS :
β’ Hemorrhage
β’ Perforation
β’ Peritonitis
β’ Bowel obstruction
β’ Abscess - paracolic, subhepatic, subphrenic
β’ Fistula - colovesical, colovaginal, colocutaneous
EXPECTED COURSE/PROGNOSIS :
β’ Prognosis is good with early detection and treatment of the complications
β’ Of those with a fi rst episode of diverticulitis who are successfully managed medically, up to 67% will not
have subsequent attacks requiring hospitalization; 33% will recur. Two or three recurrences in 1-2 years is an
indication to electively remove the involved segment of colon.
β’ Of those with diverticular bleeding, up to 20% will rebleed in a period of months to years